Republic of the Philippines

Department of Health
BUREAU OF HEALTH
Dumaguete City
______________________
(Date)

This is to certify that Mr./Mrs./Miss _____________________________________________________

(Name)
________________________________________, ________________________________________________
(Position) (Place of Assignment)
has submitted for Physical Examination on this date in accordance with Ordinance No. 37, of the Honorable City
Council, requiring city government teachers and employees of Dumaguete City to undergo physical examination
every year.

Remarks: ___________________________________________________________________________

Recommendation: ____________________________________________________________________

___________________________________
City Health Officer

Republic of the Philippines

Department of Health
BUREAU OF HEALTH
Dumaguete City
______________________
(Date)

This is to certify that Mr./Mrs./Miss _____________________________________________________

(Name)
________________________________________, ________________________________________________
(Position) (Place of Assignment)
has submitted for Physical Examination on this date in accordance with Ordinance No. 37, of the Honorable City
Council, requiring city government teachers and employees of Dumaguete City to undergo physical examination
every year.

Remarks: ___________________________________________________________________________

Recommendation: ____________________________________________________________________

___________________________________
City Health Officer
 BUREAU OF HEALTH '.

MANILA
HEALTH WAMlNATlON RECORD

NAME : OFFICE :
(IfTeacher, what school)
Address: Type of Work:

AGE: SEX: CIVIL STATUS: HEIGHT cm. WEIGHT kls.

1. Respiratory System: 8. Eyes:

Color Perception
Flouragraphy:
R. Lung Vlsion Test Distant Vision
L. Lung Without Glasses:, R. Eye 1
Temperature: L.pe
2. Circulatory System: With Glasses: 8. Eye
L. Eye
Blood Pressure: vision'Test: Near Vision
Systolic: Without Glasses, R. Eye
Diastolic:' L. Eye
Pulse: With Glasses R. Eye
sitting: L. Eye
Agility Test: 9. Ears:
After 2 min.
3. Digestive System: . ... . . .... Hearing:
... R. Ear:
L. Ear:
Tickling of Watch: R. Ear:
C L. Ear:
-
4. Genito Urinary: Conversion: R. Ear:
L. Ear:
10. Nose:

12. 'Toothand Gums:

6. Lotomotor System: 13. Immunization:

14. Remarks:
7. Nervous System:
15. Recommendation:

Date of Examination Signature of Examinee

Medical Examiner
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